WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP)

[Pages:101]2021

Comprehensive Formulary

(List of Covered Drugs)

WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP)

Plans in all states

PLEASE READ: This document contains information about the drugs we cover in this plan.

HPMS Approved Formulary File Submission ID 21382, Version Number 06 This formulary was updated on 09/01/2020. For more recent information or other questions, please contact WellCare at the telephone number listed on the inside front and back covers of this formulary, or visit pdp.

Y0070_WCM_56007E_FINAL_07_C Internal Approved 07282020 09/01/2020 ?WellCare 2020

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We're Always Just a Phone Call Away!

If you're ready to enroll or have enrollment questions, call 1-888-293-5151. Representatives are available from 8 a.m. to 8 p.m., 7 days a week.

If you're already a member, call the Customer Service number for your plan listed below.

WellCare Classic (PDP), WellCare Value Script (PDP), WellCare Wellness Rx (PDP)

1-888-550-5252

PDP

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1-833-207-4241

Hours of operation Between October 1 and March 31, representatives are available Monday?Sunday, 8 a.m. to 8 p.m., Between April 1 and September 30, representatives are available Monday?Friday, 8 a.m. to 8 p.m., or

visit us anytime at pdp

TTY for all of the above...........................................................................................................................................711

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to "we," "us" or "our," it means WellCare. When it refers to "plan" or "our plan," it means WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP).

This document includes a list of the drugs (formulary) for our plan which is current as of 09/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the inside front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

What is the WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP) Comprehensive Formulary?

A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but our plan may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

? New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how torequest an exception, and you can also find information in the section below entitled "How do I request an exception to the WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP) Formulary?"

? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

? Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

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o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled "How do I request an exception to the WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP) Formulary?"

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. Youwill not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

The enclosed formulary is current as of 09/01/2020. Toget updated information about the drugs covered by our plan, please contact us. Our contact information appears on the inside front and back cover pages. The formulary will be updated monthly and posted on our website. Toget an updated printed formulary or to get information about the drugs covered by our plan, please visit our website at pdp or call Customer Service at our contact information on the inside front and back cover pages.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category "Cardiovascular." If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 79. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Our Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

? Prior Authorization: Our Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug.

? Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 18 tablets per prescription for rizatriptan 5mg. This may be in addition to a standard one-month or three-month supply.

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? Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, "How do I request an exception to the WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP) formulary?" on page III for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

? You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

? You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the WellCare Classic (PDP), WellCare Medicare Rx Saver (PDP) Formulary?

You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

? You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost sharing level.

? You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

? You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restrictionexception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we'll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 31-day supply (unless you have a prescription written for fewer days).

For more information

For more detailed information about your plan prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit .

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Our Plan's Formulary

The comprehensive formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 79.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., simvastatin).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

? NM means the drug is not available via your monthly mail service benefit. This is noted in the Requirements/ Limits column of your formulary. You may be able to receive more than one month's supply of most of the drugs on your formulary via mail service at a reduced cost share. Please see Chapter 3 of your Evidence of Coverage for more information.**

? PA stands for Prior Authorization: Please see page II for details.

? PA-NS stands for Prior Authorization for New Starts: This means that if this drug is new to you, you will need to get approval from us before you fill your prescription. If you are taking this drug at the time of enrollment, you will not be required to meet criteria for approval.

? B/D stands for Covered under Medicare B or D: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from us to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, we may not cover this drug.

? QL stands for Quantity Limits: Please see page II for details.

? LA stands for Limited Access medication. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at the telephone number listed on the inside front and back covers of this formulary.

? ST stands for Step Therapy: Please see page III for details.

? ^ = Drug may be available for up to a 30-day supply only.

**You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your home through our network mail service delivery program. You should expect to receive your prescription drugs within 10?14 calendar days from the time that the mail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at 1-866-808-7471 (TTY 711), 24 hours a day, seven days a week, or visit mailrx..

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Drug tier co-payment/coinsurance amounts

Prescription drugs are grouped into one of five tiers. To find out which tier your drug is in, look in the Drug Tier column of the formulary that begins on page 1. For more detailed information about your out-of-pocket costs for prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and other plan materials.

? Tier 1: Preferred Generic ? Brand and generic drugs that are available at the lowest cost share for this plan. o Tier 1 Preferred copayment: $0 o Tier 1 Standard copayment range: $1?19

? Tier 2: Generic ? Brand and generic drugs that Our Plan offers at a higher cost to you than preferred generics on tier 1. o Tier 2 Preferred copayment range: $1?18 o Tier 2 Standard copayment range: $2?20

? Tier 3: Preferred Brand ? Brand and generic drugs that Our Plan offers at a lower cost to you than nonpreferred drugs on tier 4. o Tier 3 Preferred copayment range: $25?45 o Tier 3 Standard copayment range: $33?47

? Tier 4: Non-Preferred Drug ? Brand and generic drugs that Our Plan offers at a higher cost to you than preferred brands on tier 3. o Tier 4 Preferred coinsurance range: 32?45% o Tier 4 Standard coinsurance range: 33?47%

? Tier 5: Specialty Tier ? Some injectables and other high-cost Brand and generic drugs. ^ Indicates specialty drugs are available for up to a 30-day supply only. o Tier 5 Preferred coinsurance: 25% o Tier 5 Standard coinsurance: 25%

Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/coinsurance and amounts.

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